Whose heads are you scanning?

[gro2001]

How would you interpret the following scenario. Patient comes to ED with blunt head trauma (from a very mild mechanism) on forehead with no symptoms beside mild HA right at the site of the impact (note not 2 inches around it either), no lac, normal neuro exam, no other concerning symptoms and signs. On DOAC. 1) ED doc images, there is a very small 2 mm subdural. Reversal to DOAC given. Admitted. Repeat CTH 6-12 hours from now unchanged. NSG consults and says d/c. 2) ED doc does not image. Pt sent home. Fast forward 4 months from now...in both cases pt gets repeat CTH from some doctor which now shows a much larger SDH/hygroma with acute on chronic blood products, mild shift, and pt has mostly HA with some mild contralateral weakness. NSG consulted again, says stops DOAC, and pt receives surgery 48 hours later with uneventful course. What would have Dr. Wyer said? Image or no image?

Would it have mattered if a tennis ball hit the pt in the head? What if said tennis ball was tossed and not hit with a racket? What if a piece of luggage slipped coming out from the overhead airplane bin and hit the pt on the head? I can think of innumerable number of other mechanisms.

Is there even a point in asking someone questions about what happened during the trauma? Based on some of the comments listed above, I suspect that many would say no and there is no reason to even ask about mechanism. Pt should go right to CT.

What is magical about age 65 and DOAC? Would medical decision making change if pt was 64.5 years old and on a DOAC? What about 62? What about even younger? Do skulls stop providing any protection once we hit 65?

With the above example, this pt had a non clinically important TBI and unfortunately it got worse over the next 4 months. That's low risk.

The only thing I can think of, in an ideal world, is that in the above example the NSG doctor will have made an appointment to see that patient in 3-4 weeks and gotten a repeat CTH regardless of symptomology. I'm not a NSG so I don't know if that is good medicine. I don't know if it's important to get a repeat CTH in the above example if the pt remains asymptomatic in perpetuity. I suspect not, but I don't know. Even if the repeat CTH in 4 weeks the SDH grew from 2mm to 5mm and otherwise normal, I don't know if that's an indication for surgery.

I just wonder with all the comments above why people even talk to and examine patients with mild blunt head trauma on DOAC. Probably just for show. The paper I quoted above says that physical gestalt doesn't miss clinically relevant TBI, at least in that study over 6 community sites and 6 academic sites, imaging about 4000 patients over a year.

Is there harm in imaging every single person with suspected mild TBI?

The thing is I'm confident that none of us here image 100%, so we do use gestalt. We just don't want to admit it.

In the scenarios you described above, the patient in scenario 2 was put in jeopardy and possibly harmed. Patients in scenario 2 usually get repeat imaging months later because someone has noticed a gradual cognitive (or motor) decline. Sometimes that is (mostly) reversed by draining the subdural at that point. Sometimes it's not. It's hard to know if less irreversible harm would have happened had it been addressed earlier through follow up exams in clinic and repeat outpatient imaging, but my suspicion is yes.

Even if there is never going to be an operative lesion there may have been other benefit to close follow up. Most importantly through outpatient neurocognitive evaluation and TBI rehab. Just because they seem roughly the same to you in terms of moving arms and legs doesn't mean there wasn't some cognitive decline that could have been prevented.

Also, the patient in scenario 1 would have likely been told to stop anticoagulation for two weeks while the patient in scenario 2 would go back and take his eliquis that night. There would be a good chance of patient 2 coming back with a worsened subdural and likely additional preventable harm.

With all respect to Dr Wyer, this is not an area on which I think he has particular expertise. Unfortunately his smug over reliance on EBM would lead him to erroneously interpret the gaps in the literature. For example, in the paper you referenced the follow up duration was 30 days. That's not long enough to be sure there were not clinically significant bleeds. Also, its the 21st century, people are pretty mobile, some of their patients may have been tourists/transient Americans/Canadians living in far away provinces/rural folks who died without representing to the same area/undocumented etc. Also, the study excluded patients on anticoagulation, so it also doesn't apply.

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[gro2001]

I guess I’m wishing there were a PECARN equivalent for >65 not anticoagulated. I see a significant percentage of elderly who hit their head but deny any headache or any symptoms, no focal deficits, no hemotympanum, etc.. The premise of PECARN as I understand it, it’s not to miss any that would require neurosurgical intervention, intubation, hospitalization for 48 hours. But I guess the key differences in the elderly is their risks anatomically (bridging veins, atrophy) are inherently different and harder to predict.

That and also because of the age related brain atrophy the exam may be normal for longer after an injury.

 

[ShockIndex]

That and also because of the age related brain atrophy the exam may be normal for longer after an injury.

You probably spend a lot more time in the neuroICU then me, so feel free to fact check me on these basic principles:

1) Clinically significant brain injury in the elderly is not limited to surgically significant - especially in elders who are anticoagulated.

2) A normal physical exam does not rule out clinically significant ICH (intracranial hemorrhage) in elderly patients; this is especially true in the elderly and anticoagulated. Plenty of elder patients with clinically significant brain bleeds have normal neuro exams, GCS of 15, and a paucity outward evidence of significant trauma.

3) We do not know of a mechanism threshold for which ICH becomes more likely in the elderly or anticoagulated. This includes whether the mechanism involves a head strike of any certain degree.

Based on these assumptions, I do not try to justify a lack of neuroimaging based on exam or GCS. I’m also reluctant to use a lack of mechanism to justify a minimalist approach, but admit that some patients with isolated extremity injuries will fall outside the scope of this thread. Moreover, I remain unconvinced by the argument that we are over-imaging elderly or anticoagulated patients with minor trauma. A previous post referenced a personal NNT of roughly 30 to find one bleed - more than acceptable in my opinion.

 

[gro2001]

You probably spend a lot more time in the neuroICU then me, so feel free to fact check me on these basic principles:

1) Clinically significant brain injury in the elderly is not limited to surgically significant - especially in elders who are anticoagulated.

2) A normal physical exam does not rule out clinically significant ICH (intracranial hemorrhage) in elderly patients; this is especially true in the elderly and anticoagulated. Plenty of elder patients with clinically significant brain bleeds have normal neuro exams, GCS of 15, and a paucity outward evidence of significant trauma.

3) We do not know of a mechanism threshold for which ICH becomes more likely in the elderly or anticoagulated. This includes whether the mechanism involves a head strike of any certain degree.

Based on these assumptions, I do not try to justify a lack of neuroimaging based on exam or GCS. I’m also reluctant to use a lack of mechanism to justify a minimalist approach, but admit that some patients with isolated extremity injuries will fall outside the scope of this thread. Moreover, I remain unconvinced by the argument that we are over-imaging elderly or anticoagulated patients with minor trauma. A previous post referenced a personal NNT of roughly 30 to find one bleed - more than acceptable in my opinion.

Yes, I agree on all counts.

 

[prolene60]

A couple years ago I had to transfer a 60 yo Male who was on Eliquis who suffered a mechanical fall. Suffered a wrist and hip fracture. Had to be transferred because his orthopedist was there. He was adamant that he didn't hit his head and had absolutely no signs of head trauma. The ED attending at the other hospital actually took the time to call me and asked why I didn't scan his head since he fell and was on blood thinners. She ended up scanning him later (and his neck) which of course were negative. I thought after that phone call that I was somehow practicing well before the standard of care until reading through some of these posts.

 

[skougess]

Interesting timing. Recently was on shift with a colleague who had an elderly woman presenting for a fall with no LOC, no thinners. No sign of head trauma but did say she mildly struck her head, though that was not her main complaint.

Epidural hematoma.

Old people get scanned.

 

[wareagle726]

I have NEVER had a radiologist come tell me "thanks so much for not scanning that patient." I have seen a patient I didn't scan come back sicker and thought "Dang I shoulda scanned that patient."

I think I recently saw something that stated there was a fairly high rate of c-spine injuries with elderly falls without obvious impact/injury. I can't recall the percentage but it was pretty high.

 

[bky3c]

I have NEVER had a radiologist come tell me "thanks so much for not scanning that patient." I have seen a patient I didn't scan come back sicker and thought "Dang I shoulda scanned that patient."

I think I recently saw something that stated there was a fairly high rate of c-spine injuries with elderly falls without obvious impact/injury. I can't recall the percentage but it was pretty high.

I once worked at a place where the radiologists complained that the ED (all of us) "ordered too many negative CTs."

 

[DocEspana]

very slowly I'm scanning less elderly people, even those on anticoagulation.

I'm extremely confident, perhaps 100% so, that nobody has died over the ensuing days of their discharge from my ER.
I've probably missed 1, perhaps 2, ditzel bleeds on CT.

Need more than "oh I bumped my head" to get a CT.

We are comfortable sending home people with chest pain who have a 30-60 day MACE of 0.5%. We ought to have similar security sending home these patients who we all know are very low risk.

It's gotten to the point that patients now expect a CTH no matter how trivial the head trauma, and they believe the skull serves no purpose other than preventing our brains from oozing out our ears all over the floor.

"You have a skull you know"

I am asking patients if thats what they think their skull is for now.